Long term survival following a medical emergency team call at an Australian regional hospital.

Objective: To investigate the long term survival of medical emergency team (MET) patients at an Australian regional hospital and describe associated patient and MET call characteristics. Design: Retrospective cohort study. Data linkage to the statewide death registry was performed to allow for long term survival analysis, including multivariable Cox proportional hazards regression and production of Kaplan-Meier survival curves. Setting: A large Australian regional hospital. Participants: Adult patients who received a MET call from 1 July 2012 to 3 March 2020. Main outcome measures: Survival to 30, 90 and 180 days; one year; and 5-years after index MET call. Results: The study included 6499 eligible patients. The cohort median age was 71 years, and 52.4% of the patients were female. Surgical (39.6%) and medical (36.9%) patients comprised most of the cohort. Thirty-day survival was 86.5% one-year survival was 66.1%. Among patients aged < 75 years, factors independently associated with significantly higher long term mortality included age (hazard ratio [HR], 3.26 [95% CI, 2.63-4.06]; for patients aged 65-74 v 18-54 years), male sex (HR, 0.71 [95% CI, 0.61-0.83]; for females) and pre-existing limitation of medical therapy (HR, 2.76; 95% CI, 2.28-3.35). Among patients aged ≥ 75 years, factors independently associated with significantly higher long term mortality included age (HR, 1.46 [95% CI, 1.29-1.65]; for patients aged ≥ 85 years), male sex (HR, 0.74 [95% CI, 0.66-0.83]; for females), and altered MET criteria (HR, 1.33; 95% CI, 1.03-1.71). Conclusions: Long term survival probabilities of MET call patients are affected by factors including age, sex, and limitation of medical therapy status. These data may be useful for clinicians conducting end-of-life discussions with patients.

Hospital-acquired complications in critically ill patients.

Background: The national hospital-acquired complications (HAC) system has been promoted as a method to identify health care errors that may be mitigated by clinical interventions. Objectives: To quantify the rate of HAC in multiday stay adults admitted to major hospitals. Design: Retrospective observational analysis of 5-year (July 2014 - June 2019) administrative dataset abstracted from medical records. Setting: All 47 hospitals with on-site intensive care units (ICUs) in the State of Victoria. Participants: All adults (aged ≥ 18 years) stratified into planned or unplanned, surgical or medical, ICU or other ward, and by hospital peer group (tertiary referral, metropolitan, regional). Main outcome measures: HAC rates in ICU compared with ward, and mixed-effects regression estimates of the association between HAC and i) risk of clinical deterioration, and ii) admission hospital site (intraclass correlation coefficient [ICC] > 0.3). Results: 211 120 adult ICU separations with mean hospital mortality of 7.3% (95% CI, 7.2-7.4%) reported 110 132 (42.6%) HAC events (commonly, delirium, infection, arrhythmia and respiratory failure) in 62 945 records (29.8%). Higher HAC rates were reported in elective (cardiac [50.3%] and non-cardiac [40.6%]) surgical subgroups compared with emergency medical subgroup (23.9%), and in tertiary (35.4%) compared with non-tertiary (22.7%) hospitals. HAC was strongly associated with on-admission patient characteristics (P < 0.001), but was weakly associated with hospital site (ICC, 0.08; 95% CI, 0.05-0.11). Conclusions: Critically ill patients have a high burden of HAC events, which appear to be associated with patient admission characteristics. HAC may an indicator of hospital admission complexity rather than hospital-acquired complications.

Outcomes of older people receiving intensive care in Victoria.

UNLABELLED: OBJECTIVE To assess trends in service use and outcome of critically ill older people (aged ≥ 65 years) admitted to an intensive care unit (ICU). DESIGN, PATIENTS AND SETTING: Retrospective cohort analysis of administrative data on older patients discharged from ICUs at all 23 adult public hospitals with onsite ICUs in Victoria between 1 July 1999 and 30 June 2011. Subgroups examined included those aged ≥ 80 years, major diagnosis categories, and those receiving mechanical ventilation. MAIN OUTCOME MEASURES: Resource use and hospital survival; also length of stay (LOS) and discharge destination trends. RESULTS: Over 12 years, 108,171 people aged ≥ 65 years were admitted to ICUs; of these, 49,912 (46.1%) received mechanical ventilation and 17,772 (16.4%) died. Despite an increase in the older age population (2.5% per annum) and acute care admissions (7.3% per annum) over the period studied, there was a net reversal in prevalence trends for ICU admissions (- 1.7% per annum; P = 0.04) and admissions of patients requiring mechanical ventilation (- 1.6% per annum) in the 8 years since 2004. Annual risk-adjusted mortality fell (odds ratio, 0.97 per year; 95% CI, 0.96-0.97 per year; P < 0.001) without prolongation of hospital or ICU LOS (P = 0.49) or discharge to residential aged care (RAC). Similar trends were noted in all a priori subgroups. CONCLUSIONS: Improved hospital survival without an increase in demand for ICU admission or RAC or an increase in LOS suggests there has been improvement in the care of the older age population.

A retrospective cohort study of the effect of medical emergency teams on documentation of advance care directives.

OBJECTIVE: To describe the longitudinal changes in documentation of advance care directives (ACDs), including limitation of medical therapy (LMT) and not-for-resuscitation (NFR) directives among patients reviewed by a medical emergency team (MET). DESIGN AND SETTING: Single-centre, retrospective cohort study at a tertiary teaching hospital in Wellington, New Zealand, from 1 October 2009 to 30 September 2010. PARTICIPANTS: Adult surgical and medical inpatients attended by the hospital's MET, which attends medical emergency calls and cardiac arrest calls. MAIN OUTCOME MEASURES: Chronology of LMT and NFR documentation rates in relation to hospital admission and MET attendance. Medical compliance with hospital NFR documentation policy. Differences in characteristics and outcomes of patients with and without documented ACDs. RESULTS: Documentation of LMT and NFR directives at admission was low (18%) in the 71 patient files included in the study. The LMT and NFR directive documentation rate before MET review (32%) doubled after MET involvement (62%). Universal NFR directive documentation was not achieved (66% NFR rate). Presence of pre-MET ACDs were associated with increased age, but this group had similar comorbidities and mortality rates to the group without directives. Presence of ACD documentation after MET review was associated with increased age, comorbidity burden and in hospital mortality. CONCLUSIONS: Compliance with hospital policy of universal documentation was low despite MET involvement. There was a strong association between ACDs and death, suggesting an opt-out culture. Further investigation is needed into the interaction between hospital systems, medical culture, human factors, and patient-centred clinical decision making.